## Most Common Cause of CKD in India and Globally **Key Point:** Hypertensive nephrosclerosis is the second most common cause of CKD globally and the most common cause in hypertensive populations, particularly in non-diabetic patients with long-standing, poorly controlled hypertension. ### Pathophysiology of Hypertensive Nephrosclerosis Prolonged hypertension causes: 1. Afferent arteriole hyalinization and sclerosis 2. Tubular atrophy 3. Interstitial fibrosis 4. Progressive glomerulosclerosis 5. Bilateral renal shrinkage (characteristic finding) ### Clinical Features Supporting This Diagnosis | Feature | Hypertensive Nephrosclerosis | Diabetic Nephropathy | |---------|------------------------------|---------------------| | **Duration of HTN** | Often 10+ years | Variable | | **Proteinuria** | Mild to moderate | Often nephrotic-range | | **Renal size** | Bilaterally shrunken | Initially normal, later atrophic | | **Retinopathy** | Absent | Often present | | **Associated findings** | LVH, atherosclerosis | Diabetic retinopathy, neuropathy | **High-Yield:** The combination of: - Long-standing hypertension (10 years) - Bilaterally shrunken kidneys on ultrasound - Mild proteinuria (not nephrotic) - Absence of diabetes history ...is pathognomonic for hypertensive nephrosclerosis. ### Why Hypertensive Nephrosclerosis is Most Common in This Context **Clinical Pearl:** In India and South Asia, hypertension is increasingly recognized as a major cause of CKD, rivaling diabetes in prevalence. The patient's clinical presentation—long duration of HTN, bilateral renal atrophy, and mild proteinuria—fits the classic pattern. **Mnemonic:** **HASH** = **H**ypertension → **A**rteriolar sclerosis → **S**hrunk kidneys → **H**ypertensive nephrosclerosis [cite:Harrison 21e Ch 279]
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